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Haematology

Learn about various blood products, their indications, administration details, and coagulation disorders like DIC. Get insights on managing warfarin overdoses, including vitamin K administration, and tackling Dabigatran-related bleeding.

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Haematology

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  1. Haematology

  2. Help I need blood! Both O negative and group specific are unsuitable for patients with antibodies…

  3. How well do you know your blood products? • FFP • How long does it take? …… 30mins • Does it need to be XM’ed? …. Yes • What does it contain? …. All CF’s + fibrinogen ….. BUT it’s large volumes and needs to be thawed • When else to use? …warfarin, factor deficiencies, TTP • Cryo • How long does it take? …..30mins • Does it need to be XM’ed? …..preferable • What does it contain? …VIII, XIII, fibrinogen, vWF • When else to use? ….just in bleeding when fibrinogen <1 • Platelets • How long does it take? …. 15-30mins • Does it need to be XM’ed? ….no • When else to use? …..ITP, DIC, bleeding and more… • Prothrombinex • How long does it take? ……theoretically stat • Does it need to be XM’ed? …..no • What does it contain? …II, V, VII, IX, X, antithrombin, heparin • When else to use? …. Warfarin, factor deficiencies, significant bleeding • Do I need haematology consent to use it? ……no • Where is it stocked? …..blood bank • How do I get it? …..fill out form just like blood

  4. Picture from JehovahsWitness.net – highly recommended source material

  5. What about factor VIIa? • Trials have not identified clinically significant improval of outcome • Increased mortality in blunt trauma • 5% increased risk of VTE • Indications? • As last resort in generalised bleeding only if control of bleeding has been obtained

  6. Massive Transfusion • Definition of massive transfusion? • >50% patient’s blood volume at once • 100% patient’s blood volume over 24hrs • Prognosis: 45-65% survival rate Name the movie…

  7. Fill in the blanks… Remember ratio PRBC : FFP : plt : cryo 5 : 5 : 1-2 : 1-2

  8. In Summary… • O neg • 2iu PRBC + 2iu FFP • 4iu PRBC + 4iu FFP + 3iu cryo • 4iu PRBC + 4iu FFP + 1iu plts • Alternate the above • Check bloods every 30mins • Aim INR <1.5, APTT <40, fib >1, plts >75, Ca >1

  9. DIC • What is it? • Acquired diffuse inappropriate intravascular coagulation with 2Y fibrinolysis or inhibition of fibrinolysis  microvascular thrombi, consumptive coagulopathy  ARF, ARDS, ALF, CCF, bleeding, purpura fulminans, gangrene

  10. Part II Pneumonic • H Hepatic failure • O Obstetric (eg amniotic fluid embolism, eclampsia, fetal death, placental abruption, septic abortion) • T Trauma (eg. Fat embolism, rhabdo, HI, burns, envenomation, hypothermia) • M Malignancy • I Immune (eg. Rejection, tranfusion reaction, anaphylaxis) • S Sepsis (esp G-ives) • S Shock

  11. Management • Remember this? Give Vit K to all Give PRBC if needed; May need large volumes of FFP If not bleeding, can tolerate platelets >20 Give folate supplementation; consider APC, factor VIIa; heparin if organ survival is threatened by thrombus

  12. Warfarin Overdose • Remember basics • Charcoal if <1hr

  13. Summary before the test… • INR <5 and stable • If normal INR and no therapeutic need • Give 10-20mg PO Vit K • Discharge with repeat INR in 48hrs • If INR <5 and therapeutic need • Omit dose • Consider 10% dose reduction

  14. INR >5 and stable • If no therapeutic need • 10mg IV Vit K • Consider discharge with follow up INR • If therapeutic need • Don’t overshoot • Consider 1-5mg PO Vit K • Recheck INR at 6-12hrs and give repeat dose until INR <5 then restart warfarin at lower dose • Heparin if INR <2 and at high risk

  15. INR >5 and stable but high risk • Active peptic ulcer • Recent OT in 2/52 • On aspirin • Plt <50 • INR >9 • PO / IV Vitamin K • Consider PTX (25-50iu/kg depending on INR)

  16. INR >5 and unstable / life threatening bleed • ICH, spinal, intra-abdominal, intraocular • Haematemesis, melaena, significant haemoptysis • SBP <90 • Oliguria • Decr Hb >20 • Or “at risk of significant bleeding” – use common sense • 1-2iu FFP • 50iu/kg PTX • 5-10mg IV Vit K

  17. Vit K can be given as slow IV push over 2-3mins IV Vit K onset of action: 3-6hrs PO Vit K onset of action: 6-24hrs PTX onset of action: 15mins After PTX completed (3ml/min, 500iu in 20ml therefore up to 140ml needed to give 50iu/kg to 70kg male) can repeat INR after 15mins. Repeat dose as necessary as per INR.

  18. Dabigatran • Mechanism of action • Direct thrombin inhibitor • Duration of action • 12-24hrs • Longer if renal impairment • Reversal agent • There is none • Treatment • Treat as per any haemorrhagic episode • Additional measures to ‘reverse’ if ‘significant bleeding’ and above not working • There is no published data on dabigatran reversal

  19. What do coagulation tests mean in dabigatran??? • There is no linear correlation between blood tests and bleeding risk • APTT • Higher risk of bleeding if >80, but <80 ‘may be acceptable’; moderate sensitivity • PR / INR • Higher risk if >1.5; lower sensitivity • dTCT • Very sensitive; levels >80 seen in low or high dabigatran levels • APTT and PR normal = low risk • APTT <50 and PR <1.5 = levels ‘probably low to moderate’ • Can you do dabigatran levels? • Yes • Therapeutic = 0.09mcg/ml (trough) to 0.18mcg/ml (peak) • If level <0.1mcg/ml and CrCl >30, then levels will decrease over 12-24hrs • Threshold for dialysis UNKNOWN

  20. Rever

  21. In Summary • Stop dabigatran • If OD – consider charcoal • Check bloods, inc TCT, and crossmatch • Vit K + tranexamic acid (easy to do) • If bleeding: fluids, RBC, FFP • If plt <80 or on anti-plt: plts • If bad bleeding / brain bleeding: PTX + factor VII • If severe and renal failure: haemodialysis

  22. Neutropenic Sepsis • Febrile neutropenic patient has >60% likelihood of ‘being infected’, and 37% chance of +ive blood culture (usually G-ives) • What’s the definition of neutropenic sepsis? • T >38.5 (or >38 twice over 2hrs) • Neutrophils < 1.0 X 109/L • Assessment • 2x blood cultures • Central and peripheral blood cultures if line • Take down dressing and check site if recent aspirate / line

  23. Treatment of Low Risk Patient

  24. Treatment of High Risk Patient • What’s a high risk patient? (hidden on haematology website) • Neutrophils <0.5 • “Rapid decrease” in neutrophils • “Protracted” neutrophils <0.5 • “Other contributing factors” eg. Immunocompromised, steroids, central line, GVHD • BMT patient with impaired B and T cell function

  25. Treatment of High Risk Treatment

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